Medicines’ Promotional Practices
Promotional activities are largely centred in the big cities such as Karachi, Lahore, Islamabad, Multan, Peshawar and Quetta, etc. However, teams of trained and skillful medical sales representatives are spread throughout the country, promoting their medicines using multiple detailing aids such as brochures and product literature [65].
Despite the presence of legislation governing advertisement and promotion of pharmaceuticals (the Drugs Act, 1976), the pharmaceutical companies encourage prescribers to recommend their products. However, it is common knowledge that they use unethical marketing practices to promote medicines [80]. Most of the companies spend 20-30% of their revenue on marketing [80]. Vigilant inspection of promotional activities of pharmaceutical companies is needed by the DRAP to tackle this issue.
The Role of Pharmacist in Community and Hospital Environments
Traditional pharmacy education institutes and the number of professional pharmacists were very low, with the number of institutes offering pharmacy education (graduate degree programmes) <10 in 2000 [81], which has now increased to 34 (17 public sector and 17 private sector institutes) [82]. Pharmacy graduates are also increasing after the initiation of Pharm-D degree (a 5-year clinical oriented programme) in 2003. Since then, the pharmacist began to have a more prominent role in hospitals, industry, retail stores and pharmaceutical marketing. But, the profession and the professionals are still neglected in the healthcare system of Pakistan [83].
There are 8102 pharmacists and 31,000 pharmacy technicians in the country [69]. There are two types of licences: Category A and Category B. The qualified and registered pharmacists are ‘Category A’ licence-holders, and they can dispense all medicines, while pharmacy technicians having a 2-year diploma possess ‘Category B’ licence under which they can perform activities including compounding and dispensing under the supervision of a qualified pharmacist. These licences are provided by the Pharmacy Council under the Pharmacy Act, 1967 [84].
There are approximately 80,000 medical stores or private pharmacies in Pakistan [31]; however, these pharmacies are of varying quality. According to law, pharmacists have to be present in those pharmacies; however, that is not the case in all pharmacies. There is a shortage of pharmacists in the country (2587/year). Also, the absence of reasonable drug storage, compounding and record-keeping as per the legislation stated in the Pharmacy Act 1967 also add to the problem [69].
Similar is the case of public sector hospitals where a small number of pharmacists are available [31]. About 10 pharmacists are appointed in each of the tertiary care hospitals, and one or two are appointed at secondary care hospitals. The pharmacists working in hospital environments account for <15% of the total pharmacists in the country [85]. There are no pharmacists appointed at the BHU level. Likewise, in most of the private sector hospitals, there are no pharmacists. According to an estimate, only 0.06 pharmacists are in reach of 10,000 people in Pakistan, compared to the international standards of availability of five pharmacists per 10,000 person population [31]. Those present in hospitals are restricted to the drug storage areas and have limited opportunities to perform patient-oriented services. In the area of drug regulation, only one pharmacist is present at Tehsil level, and two or three pharmacists are working at the district level as drug inspectors [85].
The pharmacist’s role is not well established in Pakistan. They are being neglected in the healthcare system and are not remunerated appropriately [86, 87]. However, we hope that the recent attempts by the government to allocate pharmacists in public hospitals, forensic laboratories, DRAP, DTLs and customs department hopefully will improve the role of pharmacist in the country. Moreover, efforts of DRAP to ensure the presence of a pharmacist at all pharmacies and some chain pharmacies in urban areas (Fazal Din’s Pharma Plus, Mahmood Pharmacy, Clinix Plus [88], Green Plus Pharmacie [89] and Servaid Pharmacy [90]) will also strengthen the role of pharmacist in Pakistan.
Pharmaceutical care involves patient-centred services of a pharmacist. It includes all actions performed by a pharmacist for the benefit of the patient to achieve the maximum therapeutic outcome and to improve overall the quality of life of a patient [91]. However, pharmaceutical care interventions are lacking in the country, except for a few private sector hospitals such as SKMCH&RC and AKUH which have well-established pharmacy systems and pharmacists performing patient-oriented services [74, 75].
Medicines Use Research (Including Drug Utilization Evaluation Research)
Drug utilization research is defined by WHO as a process that involves marketing, distribution, prescription, dispensing and safe administration of drugs by keeping medical and socioeconomic factors under consideration [91]. Pakistan lags behind the highly developed countries in the field of medicines use research. There is no specific organization solely working to investigate drug utilization in the country.
It is important to keep track of every step of drug, from manufacturing, import to dispensing and then perhaps medicine use by the patients. Medicine information system, electronic prescribing, documentation of patient registries and involvement of pharmacists in decision-making are also vital to improve healthcare.
